What is the treatment for cavernous sinus thrombosis?

Treatment of Cavernous Sinus Thrombosis

The treatment of cavernous sinus thrombosis (CST) requires immediate anticoagulation with either intravenous unfractionated heparin or subcutaneous low molecular weight heparin, along with broad-spectrum antibiotics, even in the presence of hemorrhagic changes. 1

Diagnostic Considerations

CST is a potentially life-threatening condition with high morbidity and mortality rates. Early recognition is crucial for optimal outcomes. Key diagnostic features include:

• Clinical presentation: Fever, headache, ocular manifestations (chemosis, periorbital edema, ptosis, ophthalmoplegia, vision changes) 2
• Cranial nerve involvement: CN VI (lateral rectus palsy) most commonly affected, followed by CN III, IV, and V 2
• Imaging:
  • MRI with MR venography (MRV) is the preferred first-line imaging modality with highest sensitivity 1
  • CT with CT venography (CTV) is a reasonable alternative when MRI is contraindicated or unavailable 1

Treatment Algorithm

1. Immediate Management

• Anticoagulation:

  • Start either intravenous unfractionated heparin or subcutaneous low molecular weight heparin 1
  • Recent evidence strongly suggests anticoagulation improves mortality (adjusted odds ratio 0.067) 3
  • Non-heparin based anticoagulants should be considered if there is concern for heparin-induced thrombocytopenia 1

• Antimicrobial Therapy:

  • Initiate broad-spectrum antibiotics immediately to cover common pathogens:
    • Staphylococcus aureus
    • Streptococcal species
    • Oral anaerobic species
    • Gram-negative bacilli 2
  • Consider antifungal therapy if invasive fungal sinusitis is suspected 4

2. Surgical Intervention

• Sinus Drainage:

  • Functional endoscopic sinus surgery to drain the primary site of infection when sinusitis is the underlying cause 5
  • Surgical debridement for invasive fungal sinusitis 4

• Advanced Interventions:

  • Endovascular therapy with or without mechanical thrombus disruption may be considered in severe cases or patients who fail to improve on anticoagulation 1
  • Decompressive hemicraniectomy for patients with parenchymal lesions leading to herniation 1

3. Duration of Treatment

• Anticoagulation Duration:

  • 3 months for transient risk factors
  • 6-12 months for idiopathic thrombosis or mild thrombophilia
  • Lifelong for high-risk thrombophilia, recurrent events, or antiphospholipid syndrome 1
  • Heparin is the most frequently used initial agent, with one-third of patients receiving anticoagulants for three months 3

• Antibiotic Duration:

  • Long-term intravenous antibiotic therapy is critical for optimal clinical outcome 6

Monitoring and Follow-up

• Close neurological monitoring during the acute phase
• Follow-up imaging with MRV or CTV at 3-6 months to assess recanalization 1
• Early follow-up imaging for patients with persistent or evolving symptoms despite medical treatment 1

Special Considerations

• Patients with hyperglycemia should be carefully evaluated before receiving anticoagulation 3
• For CST secondary to invasive fungal sinusitis, voriconazole may be the preferred antifungal agent 4

Prognosis

Despite optimal management, CST carries significant morbidity including potential vision loss and cranial nerve deficits. Early intervention with anticoagulation has been shown to significantly reduce mortality rates from 18% to 3.3% 3.